MEDICARE: LILY DENTAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598415655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LILY DENTAL PC

Provider Business Mailing Address
First Line	:	837 59TH ST FL 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-5577
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	837 59TH ST FL 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-5577
Country	:	US
Telephone Number	:	718-576-1558
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	YUNBO SONG
Credential	:
Telephone Number	:	718-576-1558

Provider Enumeration Date	:	03/23/2022
Last Update Date	:	09/26/2024

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